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Jubouri M, Surkhi AO, Al-Tawil M, Geragotellis A, Abdaljawwad TZI, Qudaih M, Elrayes MIR, Dewi M, Moothathamby T, Hammad A, Mohammed I, Awad WI, D'Oria M, Piffaretti G, Bailey DM, Williams IM, Bashir M. Long-Term Survival and Reintervention Following Thoracic Endovascular Aortic Repair in Blunt Traumatic Thoracic Aortic Injury: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 109:162-176. [PMID: 39004278 DOI: 10.1016/j.avsg.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 04/02/2024] [Accepted: 04/28/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma. Different management strategies are available with varying clinical outcomes. However, thoracic endovascular aortic repair (TEVAR) has become the first-line option for most BTAI patients, mainly owing to its minimally invasive nature, yielding improved immediate results. This meta-analysis aims to investigate mortality, long-term survival, and reintervention following TEVAR in BTAI. MATERIAL AND METHODS A systematic review conducted a comprehensive literature search on multiple electronic databases using strict search terms. Twenty-seven studies met the set inclusion/exclusion criteria. A proportional meta-analysis of extracted data was conducted using the Comprehensive Meta-Analysis Software, v.4. RESULTS 1498 BTAI patients who underwent TEVAR were included. Using the SVS grading system, 2.6% of the population had Grade 1 injuries, 13.6% Grade 2, 62.2% Grade 3, 19.6% Grade 4, and 1.9% unspecific. All-cause mortality did not exceed 20% in all studies except one outlier with a 37% mortality rate. Using the random effects model, the pooled estimate of overall mortality was 12% (95% confidence interval [CI], 5.35-8.55%; I2 = 70.6%). This was 91% (95% CI, 88.6-93.2; I2 = 30.2%) at 6 months, 90.1% (95% CI, 86.7-92.3; I2 = 53.6%) at 1 year, 89.2% (95% CI, 85.2-91.8; I2 = 62.3%) at 2 years, and 88.1% (95% CI, 83.3-90.9; I2 = 69.6%) at 5 years. Moreover, the pooled estimate of reintervention was 6.4% (95% CI, 0.1-0.49%; I2 = 81.7%). CONCLUSIONS Despite the high morbidity and mortality associated with BTAI, TEVAR has proven to be a safe and effective management strategy with favorable long-term survival and minimal need for reintervention. Nevertheless, diagnosis of BTAI requires a high index of suspicion with appropriate grading and prompt transfer to trauma centers with appropriate TEVAR facilities.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | | | | | | | - Mohanad Qudaih
- Faculty of Medicine, Al-Quds University, Jerusalem Palestine
| | - Mohammed I R Elrayes
- Department of Paediatric Surgery, Great Ormond Street Hospital for Children, London, UK
| | - Madlen Dewi
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Thurkga Moothathamby
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Aya Hammad
- Hull York Medical School, University of York, York, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Gabriele Piffaretti
- Vascular Surgery-Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.
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D'Oria M, Jubouri M, Piffaretti G, Franchin M, Lepidi S, Bashir M. Current expert-based opinions on endovascular treatment of blunt thoracic aortic injury: A state-of-the-art narrative review on indications, techniques, results, and challenges. Vascular 2024:17085381241254629. [PMID: 38741044 DOI: 10.1177/17085381241254629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma which warrants prompt recognition with expedited management. Clinical manifestations of BTAI may not be straightforward to detect and may be misdiagnosed. Therefore, diagnosis of BTAI requires a high index of suspicion based on the mechanism of injury along with urgent transfer to centers with appropriate expertise and facilities. METHODS We provide an expert-based narrative review on endovascular treatment of BTAI highlighting indications, techniques, results, and challenges. RESULTS Multiple imaging modalities can be used including computed tomography angiography, transesophageal echocardiography, magnetic resonance imaging, and intravascular ultrasound. Whilst conservative pharmacological management can be a safe option in low-grade BTAI, thoracic endovascular aortic repair has become the gold-standard strategy in most cases, replacing open surgical repair. Nevertheless, it is important to account for patient demographics particularly age, severity of injury, choice of endograft including its type and size, and endovascular technique including landing zone and left subclavian artery revascularization. CONCLUSIONS Overall, TEVAR in BTAI has been shown to be an efficacious strategy with favorable early outcomes. In contrast, less is known on the long-term clinical outcomes of TEVAR in BTAI. Hence, despite the optimal early technical and clinical success rates, concerns remain about the need for long-term surveillance. The exact timing of follow-up and the integration of different modalities that can also investigate potential downstream cardiovascular effects remain hot topics for future research. Finally, industry should focus on developing more compliant endografts to improve the stiffness mismatch between the endograft and the aorta to optimize results.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Matti Jubouri
- University of York, Hull York Medical School, York, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Marco Franchin
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Health & Education Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK
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Mazzaccaro D, Righini P, Fancoli F, Giannetta M, Modafferi A, Malacrida G, Nano G. Blunt Thoracic Aortic Injury. J Clin Med 2023; 12:jcm12082903. [PMID: 37109240 PMCID: PMC10142366 DOI: 10.3390/jcm12082903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Blunt thoracic aortic injury (BTAI) is a potentially fatal condition that needs prompt recognition and expedited management. Clinical manifestations of BTAI are not straight forwarding and may be misdiagnosed. The grade of aortic injury is an important determinant of perioperative mortality and morbidity, as well as the indication of treatment, along with the presence of concomitant lesions of other involved organs. The mainstay of treatment nowadays for hemodynamically stable patients who survive the trauma scene is represented by delayed endovascular repair whenever anatomically and clinically feasible. Endovascular repair, in fact, is burdened by lower perioperative mortality and morbidity rates if compared to open surgical repair, but concerns remain about the need for long-term surveillance and radiation exposure in patients who are at a younger age than patients treated for the aneurysmal disease. The aim of the paper is to provide an update on the diagnostic modalities and strategies of treatment for patients affected by BTAI.
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Affiliation(s)
- Daniela Mazzaccaro
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Paolo Righini
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Fabiana Fancoli
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Matteo Giannetta
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Alfredo Modafferi
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Giovanni Malacrida
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Giovanni Nano
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy
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Kiely K, Arko F. Two Endovascular Stent Graft Repairs Needed for an Extrathoracic Aortic Graft: Distant Complications After an Original Open Repair for a Gunshot Wound to the Chest. Tex Heart Inst J 2023; 50:491987. [PMID: 37011364 PMCID: PMC10178647 DOI: 10.14503/thij-22-7850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Although the management of traumatic injuries to the thoracic aorta has shifted toward endovascular management, the historical standard of care is open reconstruction. Choosing to reoperate when faced with a complication from a prior open repair can be challenging; endovascular management can be a reasonable option in this situation. This report describes a 54-year-old man with a remote history of open surgery for a traumatic injury to the descending thoracic aorta who underwent endovascular aortic stent graft placement for coverage of extrathoracic graft extension with pseudoaneurysm formation and distal embolization. He returned a year later with a type IIIb endoleak with rupture into the posterolateral chest wall. A sec ond endovascular approach was used to successfully reline the graft and exclude the rupture.
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Affiliation(s)
- Kate Kiely
- Sanger Heart & Vascular Institute, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Frank Arko
- Sanger Heart & Vascular Institute, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
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Dake MD, Brinkman WT, Han SM, Matsumura JS, Sweet MP, Patel HJ, Taylor BS, Oderich GS. Outcomes of Endovascular Repair of Aortic Aneurysms with the GORE® Thoracic Branch Endoprosthesis for Left Subclavian Artery Preservation. J Vasc Surg 2022; 76:1141-1149.e3. [PMID: 35709864 DOI: 10.1016/j.jvs.2022.05.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 01/16/2023]
Abstract
OBJECTIVE OR BACKGROUND Thoracic endovascular aortic repair has emerged as the dominant paradigm for treatment of patients with descending thoracic aortic aneurysms. For aneurysms involving the aortic arch in the region of the left subclavian artery (LSA), branch vessel preservation to maintain blood flow to the LSA is recommended. Branched aortic endografts are an alternative to surgical revascularization of the LSA. METHODS Across 34 investigative sites, 84 patients with Zone 2 aneurysm were enrolled in a nonrandomized, prospective study of a single branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for left subclavian perfusion. RESULTS Over half of the patients were male (63%). Their average age was 70 (±11) years. The aneurysm morphology was fusiform in 43 and saccular in 41 patients. The mean aneurysm diameter at screening was 56.2 mm. The mean follow up was 30 months (range 2.6 to 50.7 months). Reported here are the patient outcomes at 1 and 12 months. Pre-defined technical success with implantation of the device in landing Zone 2 was achieved in 92% (n=77) of patients. There were no cases of aortic rupture, lesion-related mortality, or new onset renal failure. There was no peri-operative (30-day) mortality. A single case each of permanent paraplegia and paraparesis occurred. Three patients experienced a procedure-related stroke. Through 12 months, four patients died; none of the deaths were adjudicated as related to the device or procedure. One aortic reintervention was required. A single case of aortic enlargement (core laboratory) was reported at 6 months. Type 1 (n=3) and III (n=5) endoleaks occurred in 9.8% of patients of which one (Type III) required reintervention. CONCLUSIONS Results from this device study in patients with Zone 2 aneurysm demonstrate that early safety and efficacy outcomes are maintained up to 12 months after the endovascular procedure with low mortality and reintervention rates and an acceptable frequency of procedural complications, including neurologic complications.
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Affiliation(s)
- Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, Tucson, AZ.
| | | | - Sukgu M Han
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Matthew P Sweet
- Department of Surgery, University of Washington, Seattle, WA
| | - Himanshu J Patel
- Joe D. Morris Collegiate Professor in Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Bradley S Taylor
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Gustavo S Oderich
- Cardiothoracic & Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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Chikwe J. Editor's Choice: Strength in Numbers. Ann Thorac Surg 2022; 113:1401-1404. [PMID: 35459448 DOI: 10.1016/j.athoracsur.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Madigan M, Lewis AJ, Liang NL, Handzel R, Hager E, Makaroun M, Chaer RA, Eslami MH. Outcomes of Operative and Non-Operative Management in Blunt Thoracic Aortic Injury. J Vasc Surg 2022; 76:239-247.e1. [PMID: 35314302 DOI: 10.1016/j.jvs.2022.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/04/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Although current guidelines for management of blunt traumatic aortic injury (BTAI) recommend intervention for grade 2 injury or higher, there is a national trend of aggressive endovascular treatment of low-grade BTAI. Little is known about the natural history of grade 1-2 injuries treated non-operatively. We hypothesized that most of these low-grade injuries remain stable with non-operative management. METHODS A review of blunt thoracic aortic injuries (BTAI) at a large referral Level 1 trauma center from 2004-2020 was performed. Injuries were graded on a standard 1-4 scale. Outcomes of both non-operative and TEVAR management strategies were compared, including post-trauma morbidity, mortality, re-intervention, and lesion stability. RESULTS 176 patients with BTAI, sufficient imaging, and follow-up were identified during the time period. 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with grade 4 injury. Of those 176 patients, 112 underwent thoracic endovascular aortic repair (TEVAR) and 64 were managed non-operatively. Most (90.2%) undergoing TEVAR had grade 3 injuries. Non-operative management was performed for 97.2% of grade 1 injuries and 62.5% of grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). Post-trauma morbidity within 30 days (stroke [3.6 vs. 3.1%], MI/arrhythmia [8.9 vs. 1.6%], respiratory failure [31.2 vs. 28.1%], acute kidney injury [9.8 vs. 12.5%], UTI [2.7 vs. 4.8%], GI bleeding [3.6 vs. 0.0%], PE [10.9 vs. 4.5%]) and 1-year mortality after discharge [1.8 vs. 3.1%] were comparable between operative and non-operative groups. Median [IQR] follow up was 1501 [475.6, 2804] days in the TEVAR group and 1170.5 [317, 2173] days in the non-operative group. There was no progression of lesions in patients with low-grade (1-2) injuries managed non-operatively. Resolution of grade 1-2 injury was seen in 20% of patients at 30 days, improving to 44% during long-term follow up. Fourteen patients with grade 3 injuries (12.2% of grade 3 injuries in this series) were also observed and did not require future intervention. These patients generally had smaller pseudoaneurysms with minimal periaortic hematoma. None progressed or resulted in rupture on follow-up (454.5 [81, 1199] days CT scan follow up). CONCLUSIONS Non-operative management of low-grade BTAI does not result in long-term aortic complications or need for reintervention. Those grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma may be safely observed if they can be appropriately followed, and that indications for treatment of select grade 3 injuries merits further consideration.
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Affiliation(s)
- Michael Madigan
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, PA.
| | - Anthony J Lewis
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, PA
| | - Robert Handzel
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, PA
| | - Eric Hager
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, PA
| | - Michel Makaroun
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical School, Pittsburgh, PA
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Mehta C. Improving the endovascular management of blunt thoracic aortic injury. Ann Thorac Surg 2021; 113:1542-1543. [PMID: 34270975 DOI: 10.1016/j.athoracsur.2021.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/20/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Christopher Mehta
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Arkes Pavilion, Ste 730, Chicago, IL, 60611.
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